The undersigned hereby authorizes __________________________________________________
School District to release copies of the following official education records:
_______________________________________________________________________________
_______________________________________________________________________________
concerning _________________________________ ___________________________________
(Full Legal Name of Student) (Date of Birth)
__________________________________________________ from 20___ to 20 ___
(Name of Last School Attended) (Years of Attendance)
The reason for this request is: _______________________________________________________
_______________________________________________________________________________
My relationship to the child is:_______________________________________________________
Copies of the records to be released are to be furnished to:
____ the undersigned
____ the student
____ other (please specify) _____________________________________________
__________________________________________
(Signature)
Date: _____________________________________
Address: __________________________________
City: _____________________________________
State: ______________________ Zip: _________
Phone Number: ____________________________
